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Question about procedures performed

  1. #1
    Location
    Daytona Beach, FL
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    Exclamation Question about procedures performed
    Medical Coding Books
    This was posted in another forum but not sure if that was the correct area so I am reposting here.

    Hopefully I can get some help with this one! My ENT repaired a Nasal dorsum defect and he wants to use codes 14060 and 15576 with dx 171.0. I'm really not sure what I am looking at with this OP report but I am having trouble seeing both these procedures and I'm not sure exactly which one he did do. I would appreciate some help with the follow OP note to clarify what codes would be the correct codes.

    PREPROCEDURE DIAGNOSIS: Nasal dorsum defect.

    PREPROCEDURE DIAGNOSIS: Nasal dorsum defect.

    PROCEDURE: Adjacent tissue transfer and nasal skin cancer wound reconstruction, dorsal nasal flap.

    PROCEDURE IN DETAIL: After proper operative consent was obtained, the patient was brought to the operating room, where general anesthesia was induced via laryngeal mask airway. The patient's head and face were sterilely prepared and draped. The wound edges were refreshed with using a Beaver blade to freshen the edges. The final wound defect size measured 1.5 cm x 1.3 cm and it was on the left nasal ala extending onto the left nasal tip. A laterally based dorsum nasal flap based on the left side was created and used to cover the nasal ala and tip defect. Deep Monocryl sutures were used followed by superficial 5-0 fast absorbing plain gut sutures. The flap had excellent viability at the conclusion of the procedure. It was bleeding when poked at all edges. The natural cosmetic lines of the nasal ala and dorsal subunits were used in order to achieve maximum cosmetic outcome. At this point, this procedure was deemed complete and the incision lines were cleaned and bacitracin was placed on the wounds. Care of the patient was returned to the anesthesiologist, who extubated him and returned him to the recovery room in good condition.

    Estimated blood loss for this procedure was approximately 25 cc. Complications were none. Findings included a 1.5 x 1.3 cm left alar/nasal tip defect.

    I would appreciate all the help I can get in understanding what it is that I am looking at!

    Thanks,
    Jodi Dibble, CPC

  2. #2
    Default
    It has to be one or the other. I know 15576 are full-thickness flaps/pedicles and for traumatic wounds. 14060 says to not use for traumatic wounds.

    Still, 14060 would be more likely and has 1 full RVU more then 15576.
    Last edited by surgonc87; 07-22-2011 at 02:20 PM.

  3. #3
    Location
    Daytona Beach, FL
    Posts
    752
    Default
    Thanks for your help surgeonc87! This was a repair for a patient who had cancer surgery, so it would not be a traumatic wound.

    Thanks!
    Jodi Dibble, CPC

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